Beruflich Dokumente
Kultur Dokumente
Insurance
a) Policy No. :
b) SL No./Certificate No.: c) Company/TPA ID No.:
d) Name :
(Surname) (First Name) (Middle Name)
e) Address :
City :
State : Pin Code :
Phone Number :
E-mail :
Ÿ Diagnosis : ___________________________________________________________________________________________________________________
f) Occupation : Service Self Employed Homemaker Retired Student Others (Please Specify) ___________
g) Address :
(if different
from above)
City :
State : Pin Code :
h) Phone Number :
i) E-mail :
Ver: Nov/16
b) Room Category occupied : Day Care Single Occupancy Twin Sharing 3 or more beds per room
i) If Injury, give cause : Self Inflicted Road Traffic Accident Substance Abuse/Alcohol Consumption
iii) MLC Report & Police FIR attached : Yes No j) System of Medicine : _______________________________________
6 (DD/MM/YYYY)
7 (DD/MM/YYYY)
8 (DD/MM/YYYY)
9 (DD/MM/YYYY)
10 (DD/MM/YYYY)
In case of more details, please attach a separate sheet.
Place : ______________________________________________
e) Qualification :
f) Registration No. with State Code :
g) Contact No. :
b) IP Registration No. :
c) Gender : M F d) Age : / (YY/MM) e) Date of Birth : / /
f) Date of Admission : / / (DD/MM/YYYY) g) Time of Admission : : (HH:MM)
e) Pre-authorization no. :
__________________________________________________________________________________________________________________________
(i) If yes, give cause : Self inflicted Road Traffic Accident Substance Abuse/Alcohol Consumption
(ii) If Injury due to Substance abuse/Alcohol consumption, Test conducted to establish this : Yes No
(If yes, attach reports)
(ii) Original Pre-authorization request : (x) CT/ MRI/ USG /HPE investigation reports :
(iii) Copy of Pre-authorization approval letter : (xi) Doctor's reference slip for investigation :
(vi) Operation Theatre notes : (xiv) MLC report & Police FIR :
(vii) Hospital Main Bill : (xv) Original death summary from hospital where applicable:
Section E - Additional Details in case of Non-Network Hospital (Only fill in case of non-network hospital)
City :
State : Pin Code :
b) Contact No. : -
c) Registration No. with State Code :
d) Hospital PAN : e) No. of inpatient beds :
f) Facilities available in the hospital : (i) OT : Yes No (ii) ICU : Yes No
(iii) Others : _____________________________________________________________________________________________________________
Place : _____________________________________________
Note: If claiming under ‘Worldwide OPD Cover’, only the relevant fields need to be filled.
Name, address and telephone number of Hospital where treatment was given: ____________________________________________________________
__________________________________________________________________________________________________________________________
Name of treating Medical Practitioner: ____________________________________________________________________________________________
Details of Illness/Injury: ________________________________________________________________________________________________________
Cause of the Illness/Injury: ______________________________________________________________________________________________________
Was the Illness/incident caused/ aggravated due to a pre-existing condition? Please give details: ___________________________________________________
__________________________________________________________________________________________________________________________
Date of onset of Illness (DDMMYYYY):
Nature of treatment: _________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Date of treatment (DDMMYYYY): From To
Loss of Passport
Date of loss (DDMMYYYY): Place of loss: ______________________________________________
Detail / Circumstances of loss: _________________________________________________________________________________________________
Total expenses: ___________________________
Medical Evacuation
If Medical Evacuation is done, reason for Medical Evacuation: _________________________________________________________________________
Medical Evacuation From: ____________________ To: ________________________ Date:
Date
To,
The Medical Suprintendent
_________________________________
_________________________________
_________________________________
Dear Sir,
Re : Authorization in favour of M/s Religare Health Insurance Company Limited and its authorized agents.
_____________________________________________________________________________________________________________________
I hereby authorise M/s Religare Health Insurance Company Limited and/or its authorised representative to seek any medical information / records from you or
from the Medical Practitioners who has attended on me in connection with the above ailment.
Thanking You,
Yours Faithfully
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